TRAVEL VACCINATION PACK
Thank you for your enquiry regarding travel vaccinations

Please read carefully and then fill in the attached questionnaire.

Please bring completed form with you to your appointment, without it the nurse cannot assess
your requirements.

Please allow plenty of time to arrange your vaccinations. Some vaccinations need to be given
3 months in advance of travel.

Some vaccinations are not kept in stock, as they are not often requested. They will be ordered
for you on a named basis and kept for your use only.

In common with other local practices we are no longer able to supply travel vaccines on the
NHS, and consequently there will be a charge for your vaccinations.

Some vaccines may need to be ordered in especially for you. If there is a charge for these
particular vaccines, they will be ordered for you upon receipt of your payment.

All patients receiving injections and vaccinations are advised to stay on the premises for 20
minutes. Please allow time for this.
Further Information is available at the following Websites
http://www.who.int/en/
http://www.masta.org/
http://www.doh.gov.uk/traveladvice/
http://www.doctorbackhome.com/
http://www.travax.scot.nhs.uk/
TRAVEL VACCINATIONS
PRICE LIST 2008
Depending on where you are visiting, there may be a charge for your vaccinations.
Typhoid
No Charge
Hepatitis A (Involves 2 vaccines over a 12 month period)
No Charge
Hepatitis B
(Involves 3 vaccines and a blood test)
70.00
Hepatitis B Booster
35.00
Hepatitis B (children)
(Involves 3 vaccines and a blood test)
70.00
Polio
No Charge
Diphtheria / Tetanus
No Charge
Twinrix – Adult (As per Hep A)
(Involves 3 vaccines and a blood test)
No Charge
Twinrix – Junior (As per Hep A)
(Involves 3 vaccines and a blood test)
No Charge
Meningitis
35.00
Japanese Encephalitis (3 doses)
(Involves 3 vaccines) Named patient basis only
80.00
Rabies (3 doses)
123.00
Rabies Booster
48.00
Tic Borne Encephalitis
(Involves 2 vaccines) Named patient basis only
112.00
Tic Borne Encephalitis Booster
Named patient basis only
Subject to Availability
Cholera
(Involves 2 oral vaccines – see leaflet)
66.00
The cost and type of Malaria prevention will vary depending on your holiday destination.
Travel Vaccination Questionnaire
It will help if you answer the following questions and bring the completed questionnaire to your first
appointment with the Nurse. Please answer all the questions if possible.
First Names
Surname
Date of Birth
-
-
Duration of Trip
Departure Date
Please list all the countries you will be visiting including stop-overs and tick the relevant
region
North
Destinations
including stopovers
East
South
West
Mountainous
Please indicate the type of accommodation you
will be staying in
Hotel
Rainforest
Private House
Rural
Camping
Resort
Backpacking
Please indicate the type of areas you will be visiting
Trekking
Type of Visit
Business
Holiday
Are you Pregnant ?
Yes
No
Are you taking Steroids ?
Yes
No
Have you had any recent treatment for cancer ?
Yes
No
Have you reacted badly to any previous vaccinations ?
Yes
No
If Yes which ?
If Needing Malaria Protection Do you have a history of fits ?
Yes
No
Do you have a history of depression ?
Yes
No
Have you had any of the following vaccinations, if Yes give the approximate dates
Previous
Vaccinations
B.C.G. (Tuberculosis vaccination)
Yes
No
Date
Tetanus
Yes
No
Date
Polio
Yes
No
Date
Yellow Fever
Yes
No
Date
Typhoid
Yes
No
Date
Meningitis
Yes
No
Date
Hepatitis A
Yes
No
Date
Hepatitis B
Yes
No
Date
Rabies
Yes
No
Date
Diphtheria
Yes
No
Date
Japanese Encephalitis
Yes
No
Date
Tick Borne Encephalitis
Yes
No
Date
Cholera
Yes
No
Date
Cost
Required
Type of Vaccine
Polio
No charge
Typhoid
No charge
Hepatitis A
Hepatitis B Adult & Children
Hepatitis B Booster
Diphtheria/tetanus
Twinrix – Adult & Children
Meningitis
Japanese Encephalitis (3 doses)
Rabies (3 doses)
Rabies Booster
Tic Borne Encephalitis
No charge
70.00
35.00
No charge
No charge
35.00
80.00
123.00
48.00
112.00
Subject to
availability
Tic Borne Encephalitis Booster
Cholera
66.00
* Recommendations are made by the Department of Health
TOTAL COST OF ALL VACCINES GIVEN
£
The cost and type of Malaria prevention will vary depending on your holiday destination.
PATIENT CONSENT:
I have received and understood the advice given to me concerning:
 Travel vaccination requirements
Prophylaxis
Preventative


Measures

For
 For Myself
SIGNATURE:
Anti-Malarial
General
DATE:
My
Child